Perspective:

The following are 10 points to remember about these guidelines for prevention of stroke in patients with stroke and transient ischemic attack (TIA):

1. Initiation of blood pressure (BP) therapy is indicated for previously untreated patients with ischemic stroke or TIA who, after the first several days, have an established BP ≥140 mm Hg systolic or ≥90 mm Hg diastolic (Class I; Level of Evidence B). Initiation of therapy for patients with BP <140 mm Hg systolic and <90 mm Hg diastolic is of uncertain benefit (Class IIb; Level of Evidence C).

2. Statin therapy with intensive lipid-lowering effects is recommended to reduce risk of stroke and cardiovascular events among patients with ischemic stroke or TIA presumed to be of atherosclerotic origin and a low-density lipoprotein cholesterol (LDL-C) level ≥100 mg/dl with or without evidence for other atherosclerotic cardiovascular disease (ASCVD) (Class I; Level of Evidence B).

3. After a TIA or ischemic stroke, all patients should probably be screened for diabetes mellitus (DM) with testing of fasting plasma glucose, glycated hemoglobin (HbA_1c), or an oral glucose tolerance test. Choice of test and timing should be guided by clinical judgment and recognition that acute illness may temporarily perturb measures of plasma glucose. In general, HbA_1c may be more accurate than other screening tests in the immediate postevent period (Class IIa; Level of Evidence C).

4. For patients who are able and willing to initiate increased physical activity, referral to a comprehensive, behaviorally oriented program is probably recommended (Class IIa; Level of Evidence C). It is reasonable to conduct a nutritional assessment for patients with a history of ischemic stroke or TIA, looking for signs of overnutrition or undernutrition (Class IIa; Level of Evidence C).

5. A sleep study might be considered for patients with an ischemic stroke or TIA on the basis of the very high prevalence of sleep apnea in this population and the strength of the evidence that the treatment of sleep apnea improves outcomes in the general population (Class IIb; Level of Evidence B).

6. Carotid angioplasty and stenting (CAS) is indicated as an alternative to carotid endarterectomy (CEA) for symptomatic patients at average or low risk of complications associated with endovascular intervention when the diameter of the lumen of the internal carotid artery is reduced by >70% by noninvasive imaging or >50% by catheter-based imaging or noninvasive imaging with corroboration and the anticipated rate of periprocedural stroke or death is <6% (Class IIa; Level of Evidence B). It is reasonable to consider patient age in choosing between CAS and CEA. For older patients (i.e., older than ≈70 years), CEA may be associated with improved outcome compared with CAS, particularly when arterial anatomy is unfavorable for endovascular intervention (Class IIa; Level of Evidence B).

7. For patients with recent stroke or TIA (within 30 days) attributable to severe stenosis (70%–99% of a major intracranial artery), the addition of clopidogrel 75 mg/d to aspirin for 90 days might be reasonable (Class IIb; Level of Evidence B).

8. For patients who have experienced an acute ischemic stroke or TIA with no other apparent cause, prolonged rhythm monitoring (≈30 days) for atrial fibrillation (AF) is reasonable within 6 months of the index event (Class IIa; Level of Evidence C).

9. Vitamin K antagonist (VKA) therapy (Class I; Level of Evidence A), apixaban (Class I; Level of Evidence A), and dabigatran (Class I; Level of Evidence B) are all indicated for the prevention of recurrent stroke in patients with nonvalvular AF, whether paroxysmal or permanent. The selection of an antithrombotic agent should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including renal function and time in international normalized ratio (INR) therapeutic range if the patient has been taking VKA therapy. Rivaroxaban is reasonable for the prevention of recurrent stroke in patients with nonvalvular AF (Class IIa; Level of Evidence B).

10. Voluntary hospital-based programs for quality monitoring and improvement are recommended to improve adherence to nationally accepted, evidence-based guidelines for secondary stroke prevention (Class I; Level of Evidence C).